"I'm Having A Heart Attack"

Looking at that 12 lead in conjunction with the patient's symptoms I'm seeing a Sinus rhythm with a RBBB with PVC's, there are (as of now) no signs of infarct, to call those T waves symmetrica/hyperacute and evidence of LAD occlusion is tempting but considering the Hx they are more than likely Hyper K. If I was on a truck at this moment I would really want an SpO2 pleth so that I could see if every PVC is really getting through, I've been confused by the radial pulse one too many times. If the rate is indeed 35 (which I don't believe) with a blood pressure that high being of a different source (chronic medical conditions) I would lower the pressure and continue monitoring cardiac (12 lead every 5 min). Paying attention to signs of stroke I would also like to confirm this pressure manually. SL Nitro would be necessary at this time. BB's would be contraindicated. ASA given prior.

The pulse rate is confirmed with a good pleth wave, I did not print that. The blood pressures were all taken manually. The patient is neurologically intact.

This is really a great scenario, Tigger! It's quite complicated, and to be honest I'm not entirely sure what to do.

First of all, one strip shows bigeminy, but the other does not. Was he continually in bigeminy? This is important as it would determine how I would treat him. I would also make sure that I'm getting accurate BP's.

If he is continually in bigeminy and his PVC's are not creating a pulse, then this bradycardia needs to be addressed. Is the bradycardia due to ischemia from a developing MI? I don't see any ST elevation, but I won't rule that out. Or, is the bradycardia due to the extreme high blood pressure that his not-so-healthy heart has to pump against? Is the hypertension a response to the bradycardia, or is it a stress response? It's a couple of chicken-or-egg questions!

In a nutshell, I want to both bring up his heart rate and bring down his BP. This is what makes the patient complicated.

So, two things have to be corrected--the bradycardia and the hypertension. Certainly giving him some benzos would be a good place to start. My first thought is to start pacing him. If the hypertension is due to the bradycardia, and the chest pain and probably ischemia due to the hypertension, then by pacing him we could get him to a normal rate and thereby bring down his blood pressure. If it was a very short transport to a cath lab, then I would not do this, but considering the distance given in this scenario, I would not want to transport someone with underlying heart disease this far while he having massive chest pain and a massively high BP. Pacing this already very anxious guy is obviously not going to be easy, and again, I would be liberal with benzos and pain control.

Atropine is a consideration, and it would be easier on him that pacing, but once we give it we can't just turn it off again due to its long half life.

Aspirin and a spray of nitro would be okay. But, I don't think treating the BP with nitro would be appropriate, nor would giving anything else that only addressed his BP without also bringing up his heart rate.

This is definitely a time where I would consult with a doc at the receiving hospital. I look forward to seeing how you guys would treat this patient. Again, great scenario!

Everything about this guy screams "recommend immediate referral to a heart attack centre and take him there by ambulance".

I would give him aspirin and try one spray of GTN, gain IV access and give him pain relief if he wants it. I'd start with entonox (or methoxyflurane if entonox is contraindicated) and give him some IV morphine if that didn't work

As for his bradycardia, if it is not symptomatic I am not overly concerned about it to be honest.

BP of 260 is a bit worrying, but he does have PMHx of HTN so for him that might be normal, does he know what his BP usually is?

Bottom line from me is treat as above, take to a PCI-capable hospital and if he gets significantly worse, seek clinical advice.

SpecialK said:

BP of 260 is a bit worrying, but he does have PMHx of HTN so for him that might be normal, does he know what his BP usually is?

Click to expand...

I don't think it's possible for anyone's "normal" BP to be well into hemorrhagic stroke territory...

Underoath87 said:

I don't think it's possible for anyone's "normal" BP to be well into hemorrhagic stroke territory...

Click to expand...

It would be unusual yes, but anything is possible in medicine. I have seen a normal hypertensive BP of 220.

SpecialK said:

It would be unusual yes, but anything is possible in medicine. I have seen a normal hypertensive BP of 220.

Click to expand...

Maybe but this guy is clearly symptomatic with a very abnormal EKG. It's not normal for him.

zzyzx said:

This is really a great scenario, Tigger! It's quite complicated, and to be honest I'm not entirely sure what to do.

First of all, one strip shows bigeminy, but the other does not. Was he continually in bigeminy? This is important as it would determine how I would treat him. I would also make sure that I'm getting accurate BP's.

Click to expand...

Indeed, that 12 lead was the only time he was not in continued bigeminy.

We (my partner really, I thought ALS was magic at the time) elected to treat the bigeminy with a lidocaine, he converted following a 1mg/kg bolus. A 2mg/min lido drip was started, and this kept the bigeminy at a bay for a while though eventually it was turned up to three to keep a sinus rhythm. His BP came down to the 190s and the patient became entirely asymptomatic. He received aspirin and subsequent 12 leads were unremarkable. No NTG as the patient no longer had chest pain and this system does not like it for anything but that.

Alan L Serve said:

Maybe but this guy is clearly symptomatic with a very abnormal EKG. It's not normal for him.

Click to expand...

It's likely not normal for him no but the only thing I have to reduce his blood pressure is sublingual GTN and I'm not very keen on using for a purpose I know absolutely nothing about.

If the hospital want to do it then they can go for it like a skinned cat.

Tigger said:

Indeed, that 12 lead was the only time he was not in continued bigeminy.

We (my partner really, I thought ALS was magic at the time) elected to treat the bigeminy with a lidocaine, he converted following a 1mg/kg bolus. A 2mg/min lido drip was started, and this kept the bigeminy at a bay for a while though eventually it was turned up to three to keep a sinus rhythm. His BP came down to the 190s and the patient became entirely asymptomatic. He received aspirin and subsequent 12 leads were unremarkable. No NTG as the patient no longer had chest pain and this system does not like it for anything but that.

Click to expand...

Huh? Your partner treated a bigeminy with an underlying sinus bradycardia in the 30s with lidocaine? That's a big contraindication, for obvious reasons.

zzyzx said:

Huh? Your partner treated a bigeminy with an underlying sinus bradycardia in the 30s with lidocaine? That's a big contraindication, for obvious reasons.

Click to expand...

Not so obvious to me I guess. It was a case presented in class as well. These do not appear to be escape beats and this isn't a heart block. The patient is having 60 PVCs a minute and is symptomatic, it would appear that lidocaine should be considered, as could atropine.

Sounds like your partner was really old school.
Treating PVC's with anti-dysrhythmics is no longer recommended, though I don't doubt you'll find some old ER docs that will do it.
However, it is a clear contraindication to treat bigeminy with lidocaine when the underlying rhythm is 30.

This is a complicated case, and I'm looking forward to see how other providers would have treated this guy.

zzyzx said:

Sounds like your partner was really old school.
Treating PVC's with anti-dysrhythmics is no longer recommended, though I don't doubt you'll find some old ER docs that will do it.
However, it is a clear contraindication to treat bigeminy with lidocaine when the underlying rhythm is 30.

This is a complicated case, and I'm looking forward to see how other providers would have treated this guy.

Click to expand...

At least here, treating non-symptomatic PVCs is not recommended. If the patient is symptomatic the expectation is that they will be managed, or so says our QI. I guess I am still unclear on how it's a contraindication. If it was a rate of 30 in the context of a block or escape rhythm, absolutely.

if it's 30 apical, I'm going to opt for I.V 18 g left AC if possible, with a lock..

I'd give atropine 0.5mg, I'd give morphine for discomfort(going for >60 palpable, since the pvc's are interfering with the monitor) continue monitoring all the way in, document.

hosejockey said:

if it's 30 apical, I'm going to opt for I.V 18 g left AC if possible, with a lock..

I'd give atropine 0.5mg, I'd give morphine for discomfort(going for >60 palpable, since the pvc's are interfering with the monitor) continue monitoring all the way in, document.

Click to expand...

I ran out of time to edit... Anyways, it's hard. My concern is 30 isn't life sustaining. It feels like there's a lot of ways to look at this. I'm glad I came across this.

So, what's the answer?
I just had this pt and had a WTF moment...
54 yom, pacemaker placed last week, currently in bigeminy with a rate of 45 and BP of 190/90. Chest "soreness" from the implant last week; says he cannot differentiate whether he has CP (as we mean it) with mild nausea and mild SOB when asked specifically about these symptoms. Pt has some numbness to extremities (unsolicited).

Treat the brady despite high BP? Treat the bigeminy though there is a low underlying pulse rate? Get an IV and ready to prepare for him to crash while hoping he makes it for the ride?? Also, preferred hospital is 40+ minutes by ground (probably 60 mins with traffic).


Sent from my iPhone using Tapatalk

Also, said pt was very concerned that we let his dogs out and make sure to leave a cell phone in a certain spot on the counter...




Sent from my iPhone using Tapatalk

gotshirtz001 said:

So, what's the answer?
I just had this pt and had a WTF moment...
54 yom, pacemaker placed last week, currently in bigeminy with a rate of 45 and BP of 190/90. Chest "soreness" from the implant last week; says he cannot differentiate whether he has CP (as we mean it) with mild nausea and mild SOB when asked specifically about these symptoms. Pt has some numbness to extremities (unsolicited).

Treat the brady despite high BP? Treat the bigeminy though there is a low underlying pulse rate? Get an IV and ready to prepare for him to crash while hoping he makes it for the ride?? Also, preferred hospital is 40+ minutes by ground (probably 60 mins with traffic).


Sent from my iPhone using Tapatalk

Click to expand...

I don't know. She elected to treat the PVCs as malignant considering the chest pain and it was effective, and when it was brought up in class that was said to be fine, though not much elaboration. I've found some places that support this practice (http://www.aafp.org/afp/2002/0615/p2491.html, this anesthesia text) or at least say consider it. I'm still not sure why it's so contraindicated in this situation as @zzyzx suggests.

We run Lidocaine and I have come across warnings that administration for PVCs with underlying bradycardia could potentially cause arrest. Others that I have spoken to state you should generally treat the bradycardia over the PVCs and deal with them if still present once the rate has improved. I was working the engine that day but with so many different issues going on concurrently, I would probably make a base call if I were the transporting medic and the hospital were any further than around the corner.


Sent from my iPhone using Tapatalk

gotshirtz001 said:

We run Lidocaine and I have come across warnings that administration for PVCs with underlying bradycardia could potentially cause arrest. Others that I have spoken to state you should generally treat the bradycardia over the PVCs and deal with them if still present once the rate has improved. I was working the engine that day but with so many different issues going on concurrently, I would probably make a base call if I were the transporting medic and the hospital were any further than around the corner.


Sent from my iPhone using Tapatalk

Click to expand...

Apparently a decrease in contractility can occur at toxic dosing levels. No part of our protocols have that kinda warning, they could of course be lacking.